Richland Parish Schools
Tuition/Praxis Reimbursement Request 2014-2015
Title 1 / Title II
Instructions: Fill out one Tuition Reimbursement Request for each semester. You will be eligible for reimbursement only when the form is completed and submitted with all required documentation. Only tuition will be reimbursed during the period in which you are employed. Fees will not be reimbursed. The % of tuition reimbursement available will be based on the average tuition of Louisiana public funded universities.
1. Employee Information
Name: ______
SS# : ______Phone #______
Mailing Address: ______
______
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School: ______Grade/Subject ______
Current Classification: (circle one)
uncertified classroom teacher in an alternative certification program
certified classroom teacher seeking hours to be deemed “Highly Qualified”
certified teacher taking praxis exam to be HQ in teaching area
certified teacher completing educational leader program (acceptance prior to fall 2013)
2. Course Information
Name of university, college, or other institution offering course or test: ______
Course (s) or Test name: ______
Total credit hours earned for course or test score listed above:______
Tuition for course (s) or test listed above: ______
FOR EACH REQUEST YOU MUST ATTACH:
1. A PLAN OF STUDY THAT LIST THE ABOVE COURSES AS REQUIRED BY THE UNIVERSITY OR LOUISIANA DEPARTMENT OF EDUCATION (for tuition reimbursement)
2. COPY OF YOUR TRANSCRIPT OR FINAL GRADE (S) FOR THE SEMESTER
(For reimbursement purposes a required grade of “C” or better for undergraduate coursework, “B” or better for graduate coursework.)
(PRAXIS scores needed if requesting reimbursement for PRAXIS test.)
3. AN ORIGINAL itemized INVOICE OR RECEIPT FOR TUITION OR TESTING FEES MARKED PAID. (ITEMIZED)
Certification of Payee
I certify that this reimbursement request is just and true in all respects; that the expenses were originally paid by me and were for required expenditures in conjunction with my pursuit of certification. I will repay the district 100 percent of all reimbursed expenses if I voluntarily resign within one year after completing the course or test, and 50 percent of such costs if I voluntarily resign after one year has lapsed, but within two years after completing the course or test. I hereby agree to pay any and all balances due at that time to District in full upon demand. In the event I do not make such payment in full upon demand, I knowingly and voluntarily authorize District to deduct from my wages any amount owed by me to District under this agreement. Upon referral of this debt by District to an attorney, I further agree to pay attorney’s fees in addition to the balance I owe.
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Payee Signature LEA Authority